In 2026, the CMS-HCC Model V28 is initiated, which transforms the nature of how healthcare organizations match diagnostic codes to the financial settlement. An integrated technology platform, an efficient documentation system, and strategic planning in the Medicare Advantage, Medicaid, and ACA programs will be needed to succeed.
Healthcare reimbursement stands at a critical inflection point as regulatory changes mount, litigation increases, and coding requirements grow more complex across Medicare Advantage, Medicaid, ACA, and exchange programs. The CMS-HCC Model V28 represents the most significant transformation in risk adjustment methodology since the original HCC model introduction. With 2026 implementation rapidly approaching, healthcare organizations face the challenge of mapping diagnostic accuracy to financial outcomes in ways that demand comprehensive operational restructuring and strategic planning.
Understanding the V28 Model Framework
CMS-HCC Model V28 fundamentally restructures how diagnostic codes translate into risk scores and financial reimbursements. This new model creates more precise connections between patient conditions and actual healthcare costs.
The V28 framework introduces several critical changes that distinguish it from the current V24 system. Enhanced diagnostic code mapping captures patient complexity with greater accuracy, while refined risk coefficients better reflect actual healthcare expenditures. Updated hierarchical condition categories eliminate outdated assumptions about disease progression and treatment costs.
Key framework elements include:
- More granular condition categories that recognize specific disease stages and complications
- Enhanced demographic weighting that incorporates social determinants of health
- Expanded interaction terms between multiple chronic conditions
- Refined geographic adjustments reflecting regional care cost variations
Healthcare organizations must understand that V28 Risk Adjustment requires substantially higher documentation specificity than previous models. The system rewards precise clinical coding while creating financial penalties for vague or incomplete diagnostic information.
The Multi-Vendor Challenge in Risk Adjustment Operations
Healthcare organizations are in complicated technological landscapes that pose massive challenges in their operations. Industry executives describe having to deal with up to 30 different steps between initial documentation by the provider and final CMS submission- a process that requires a tremendous level of coordination among varied systems and platforms.
This multi-vendor complexity resembles managing interconnected puzzle pieces from different manufacturers. Each system operates with unique protocols, data formats, and integration requirements that create potential failure points throughout the risk adjustment workflow.
The operational implications include:
- Data fragmentation across disparate systems prevents comprehensive patient risk assessment
- Integration bottlenecks that delay critical documentation and coding processes
- Quality control issues stemming from inconsistent data formats and validation protocols
- Administrative burden that diverts clinical resources from direct patient care activities
Organizations preparing for CMS HCC V28 implementation must address these multi-vendor challenges through strategic technology consolidation and improved system integration capabilities.
Clinical Documentation and Coding Alignment Strategies
The inconsistency between clinical documentation and coding results in high financial risks in the V28 model. Even though physicians and medical coders have unique skills and operational requirements, effective organizations create successful alignment strategies that close operating functional distances.
Clinical accuracy directly impacts coding precision, which subsequently determines financial outcomes under V28. Healthcare providers must document patient conditions with sufficient detail and clinical specificity to support accurate HCC code assignment. Conversely, medical coders require comprehensive clinical information to identify all relevant risk factors and condition hierarchies.
Technology Solutions for V28 Implementation
The technologies of Artificial Intelligence and Natural Language Processing offer the necessary functions in order to streamline the process of V28 Risk Adjustment. The technologies carry out documentation and coding activities better and preserve clinical accuracy and overall risk capture effectiveness.
Digital Health Platform solutions address V28 challenges through sophisticated data aggregation and analysis capabilities. Advanced NLP technology processes information from multiple sources, including electronic health records, clinical data repositories, social determinants of health databases, patient-reported outcomes, and connected medical device data.
Modern AI-driven platforms offer several operational advantages:
- Automated risk identification that flags potential HCC opportunities during clinical encounters
- Documentation enhancement through intelligent prompts and clinical decision support
- Historical data analysis that identifies previously missed risk factors and coding opportunities
- Predictive analytics that forecast patient risk trajectories and inform care management decisions
Persivia CareSpace® is such an integrated environment where data is synthesized across disparate sources is rendered in the form of complete longitudinal patient records. The NLP technology in the platform is very efficient in processing unstructured clinical data, ensuring critical patient history information is available during clinical encounters.
Healthcare Interoperability and Data Flow Requirements
Effective V28 implementation demands seamless data flow across healthcare platforms and administrative systems. Organizations must develop comprehensive interoperability strategies that ensure patient information moves efficiently between clinical, coding, and financial operations.
Successful interoperability requires several foundational components. Clear data flow documentation visualizes how patient information traverses different systems and identifies potential bottlenecks or failure points. Regular integration performance evaluation measures system efficiency and identifies improvement opportunities before they impact operations.
| Integration Component | V24 Requirements | V28 Requirements | Implementation Impact |
| Data Sources | Basic EHR integration | Multi-source aggregation | Requires platform expansion |
| Processing Speed | Batch processing acceptable | Real-time processing essential | Infrastructure upgrades needed |
| Documentation Depth | General condition codes | Specific complication codes | Enhanced clinical training is required |
Building Stakeholder Trust Through Transparent Operations
Success in V28 risk adjustment requires strong relationships among patients, healthcare providers, and payers. Effective documentation serves all stakeholders when executed with transparency and clinical integrity as foundational principles.
Persivia CareSpace® addresses stakeholder trust through transparent, provider-centric solutions that provide both v24 and v28 HCC opportunities simultaneously. This dual-view capability offers both prospective and retrospective analysis, putting providers in control of risk adjustment decisions.
Key trust-building elements include:
- Transparent AI algorithms that clearly explain risk score calculations and adjustments
- Provider control mechanisms allow clinicians to accept, modify, or add HCC opportunities based on clinical judgment
- Comprehensive audit trails are used to track all the changes and decisions to be compliant
- Educational materials enable providers to learn about the linkage between documentation quality and patient outcomes
Integrated Platform Solutions vs. Multi-System Management
Healthcare risk adjustment in the future focuses on aligned solutions and not multiple fragmented solutions. The practice minimizes administrative workload, advances accuracy, and builds more efficient processes to back clinical practices as well as financial success.
The combination of platforms is a direct solution to the multi-vendor issues that healthcare organizations face. Digital Health Platform solutions provide comprehensive risk adjustment capabilities within unified systems, mitigating complexity while improving coordination between clinical and administrative functions.
CareTrak®, Persivia’s EHR-agnostic tool, enables bidirectional data exchange, ensuring that patient condition updates reflect across all connected systems. This connectivity proves crucial for V28 transition success, as documentation changes must propagate consistently throughout the technology infrastructure.
Benefits of integrated approaches include:
- Streamlined workflows that reduce manual processes and minimize error opportunities
- Consistent data management across all risk adjustment activities and reporting requirements
- Enhanced coordination between clinical documentation, coding, and financial teams
- Improved compliance capabilities through automated monitoring and reporting functions
V28 Preparation Timeline and Strategic Planning
With V28 implementation scheduled for 2026, organizations must develop structured preparation approaches incorporating comprehensive planning and strategic execution. Conference participants across the healthcare industry emphasize the importance of methodical preparation strategies.
There are some strategies that organizations need to follow when they are preparing CMS HCC V28. Incentive programs also involve clinical personnel in improving documentation and aligning individual and organizational goals. Development of the dashboard that monitors the readiness measures would give a view of progress made in the preparation and the areas where urgent focus is needed.
The preparation timeline requires careful orchestration of multiple concurrent activities:
- Technology infrastructure assessment and upgrade planning
- Clinical staff training program development and implementation
- Documentation workflow redesign and testing procedures
- Quality assurance protocol establishment and validation
- Financial impact modeling and budget planning for implementation costs
V28 Implementation Best Practices
Organizations must adopt comprehensive approaches that extend beyond basic compliance requirements. This involves a systematic assessment of how new technologies integrate with existing clinical workflows and measurement of efficiency improvements across all operational areas.
Organizations should assess new technology integration with existing workflows before implementation. Systematic efficiency measurement identifies enhancement opportunities while adaptable systems maintain operational flexibility during the transition period.
Bottom Line
The CMS-HCC Model V28 transition represents both a challenge and an opportunity for healthcare organizations. The preparation must be very thorough and cover the technology infrastructure, training of staff, and process operations in order to be successful. Companies that adopt the integrated approach will succeed, and companies that deploy outdated systems will take significant financial risks on the way to 2026.
Persivia offers the integrated platform your organization needs for V28 success. Our AI-powered solutions streamline workflows and provide transparent risk adjustment tools that healthcare providers trust.
Learn more about Persivia’s solutions.
